Assessment can be a tough question to answer. How do you assess something? Well – you’ve been doing it for your whole career. Let’s define it so you can get it down on paper easier.
Assessment has 2 main components which determine it’s composition. How we are assessing, and Why we’re assessing.
Let’s think about How;
- History
- Examination
- Investigations
And why? What are we looking for?
- Case
- Cause
- Complications
Even though how seems like it comes first, the features we look for in the HOW of assessment are informed by the WHY. So let’s expand on that quickly.
Why we assess: Case
- What are the features of the disease that are relevant right now?
- What will change your management, or alter the prognosis
Why we assess: Cause
- This, at it’s core, refers to DDx
- What features on H/E/I will tell you more about the cause of this disease?
- What features will give you differential diagnoses to consider?
Why we assess: Complications
- This goes to severity and course
- What complications or consequences of a disease are present, therefore leading to an assessment of severity?
- Conversely, which potential complications are NOT present? This may indicate less severe disease.
Seek Case, Cause and Complications in History, Examination and Investigations to define current status and directions for management, DDx, severity and course, and your assessment will be second to none!
If you’ve got another system, or you reckon there are better ways to do it, leave a comment below!